Human suffering and nursing care: multiple views
Sofrimento humano e cuidado de enfermagem: múltiplas visões
El sufrimiento humano y los cuidados de enfermería: múltiples puntos de vista
Eveline Pinheiro Beserra1
Fernanda Celedonio de Oliveira1
Islane Costa Ramos1
Rui Verlaine Oliveira Moreira1
Maria Dalva Santos Alves1
Violante Augusta Baista Braga1
1. Universidade Federal do Ceará. Fortaleza - CE, Brazil.
Corresponding Author:
Eveline Pinheiro Beserra. E-mail: [email protected]
Submited on 09/05/2012. Resubmited on 05/24/2013. Accepted on 07/06/2013.
DOI: 10.5935/1414-8145.20140026
A
bstrActObjective: To relect on sufering in the philosophical context. Methods: In this theoretical discussion sufering is presented in
diferent forms: sufering in the philosophical plane; sufering interfaces; anthropology and sufering; Nursing: a holistic view of human sufering and nursing care. Results: The nurse in their professionalpractice understands that vulnerability often is linked
with pain in the biological, psychological and social aspects, among others. One of the objectives of nursing care is alleviating human sufering caused by diseases where current technological progress sometimes helps to solve the technical management
of pain. Conclusion: Regardless of this being a technical problem, the pain and sufering are in the ethic/human sphere and should be considered in its various interfaces.
Keywords: Nursing; Pain; Anthropology; Philosophy.
r
esumoO objetivo deste estudo foi reletir sobre o sofrimento no contexto ilosóico. Métodos: Nessa discussão teórica, o sofrimento é
apresentado de formas diferentes: sofrimento no plano ilosóico; interfaces do sofrer; antropologia e sofrimento e Enfermagem: uma visão holística do sofrimento humano. Resultados: O enfermeiro em sua prática proissional compreende que a vulnerabi
-lidade, muitas vezes, está vinculada com a dor, nos aspectos biológico, psicológico e social, entre outros. Um dos objetivos do cuidado em Enfermagem é minorar o sofrimento humano causado pelas doenças, considerando que o progresso tecnológico atual ajuda, algumas vezes, a solucionar a gestão técnica da dor. Conclusão: Independente de serem um problema de ordem
técnica, a dor e o sofrimento situam-se na esfera da ética/humana e devem ser considerados nas suas várias interfaces.
Palavras-chave: Enfermagem; Dor; Antropologia; Filosoia.
r
esumenObjetivo: Comprender el sufrimiento en el contexto ilosóico. Métodos: En esta discusión teórica, el sufrimiento se presenta
de diferentes maneras: sufrimiento en el plan ilosóico; interfaces del sufrir; antropología y sufrimiento; y Enfermería - una visión holística del sufrimiento humano. Resultados: El enfermero en su práctica entiende que la vulnerabilidad se relaciona a
menudo con el dolor en los aspectos biológico, psicológico y social, entre otros. Uno de los objetivos del cuidado de enfermería es aliviar el sufrimiento humano causado por las enfermedades donde el progreso tecnológico actual a veces ayuda a resolver la gestión técnica del dolor. Conclusión: Independiente de ser un problema de orden técnica, el dolor y el sufrimiento se sitúan
en la esfera de la ética/humana y deben ser considerados en sus diferentes interfaces.
INTRODUCTION
Sufering is found at the origin of the human condition when they are confronted with the anguish of their initude. Seeking an appropriate deinition to describe it is not a subtle task. Therefore, it is necessary to use diferent visions to relect on this complex phenomenon.
Sufering is an intrinsic topic to humanity and inherent in healthcare. The nurse needs to analyze their practice on the basis of an anthropological and philosophical vision and not only technical, for which they may have conditions to understand the countless situations experienced during their professional activities and in the care human beings who are sufering1.
In this theoretical relection, the sufering is presented in diferent forms, namely: sufering on the philosophical plane; sufering interfaces; anthropology and sufering; Nursing: a holistic view of sufering; as well as human sufering and Nursing care.
Sufering on the philosophical plane
The word suffer represents an act or fact of suffering, physical pain, anguish, sorrow, bitterness, patience and resigna-tion2. The human being has sufering as inherent characteristic. Sufering presents itself as a fundamental motivation and a shelter fromthe singularity3.
However, it is necessary to consider, diferent dimensions that articulate with the individual, such as the cultural, social, educational, economic and of interpersonal nature that many times predispose them to vulnerabilities, i.e. the situation of undue or unknown risk4.
The professional must relect on the human vulnerabilities, because the recognition of this phenomenon and its relationship to the suferingis that it will be possible take care of the sufering individual in a holistic manner.
In this context, human vulnerability can be one of the possible paths for the extension of the professional sensitivity to the susceptibility of the patient, enabling them to establish a more symmetric, empathetic and supportive relationship among these5.
The nurse then must understand that vulnerability, often articulates with pain, which may be biological, psychological, spiritual and social. The latter is produced in conjunction with work precariousness and social bond fragility, being a category able to describe the situation of a large portion of the Brazilian population. To address this dichotomy that is given socially, and that becomes more acute in the case of individuals who are in relationships that make them more vulnerable, it seems that one of the possible ways that one can open the ield for the creation of a greater symmetry and equity would be through education for the citizens6.
In reality, education and citizens are articulated with the social culture of each region and clarifying that the population establishes itself in this respect. Currently, to ensure a good citizenship it is necessary that there are rights, but these need to be linked to the fulillment of their duties. Thereafter, with this two-way functioning, one can achieve the reduction of vulnerability.
Sufering interfaces
Biological sufering is a physical dimension; the pain is an indicator that something needs to be reviewed and we maysufer in the psychic dimension, which often relates to the biological aspect. Another sufering is the spiritual, added to the ques -tioning of one's identity and the search for answers.
In this diagram, it is possible to observe the intrinsic relationship that man has with vulnerability and suffering. Vulnerability in turn overcomes the individualizing and probabilistic character of the classic concept of "risk", pointing to this word as the set of aspects that go beyond the individual, encompassing collective and contextual, aspects leading to susceptibility to diseases or injuries, considering aspects regarding the availability or lack of resources devoted to the protection of individuals.
In the complexity of the human being, various components may relate to this being vulnerable, namely: biological, social, cultural, spiritual and socioeconomic aspects, but are not limited items, which may have others. Even in Figure 1, the diagram also references man with the word sufering, this word sometimes so feared by all, because when we speak of sufering, soon comes to memory an aversive experience and a corresponding negative emotion that, for many times it is associated with the pain in their various interfaces presented in any conditions.
Sufering is part of the human maturation. All, in some of the stages of life, sufer by love, nostalgia, loneliness or even by a decision. Taking new steps, this is the way,which even without realizing it, leads the human being reacting to the adversities of everyday life.
Experiencing suffering makes one closer to others, increasing self-awareness, fostering acceptance of new facts, and fosters personal maturity, which can be seen as a learning opportunity. Thus, man can contemplate the diferent vertices of sufering that are not necessarily bad. When we talk about the word sufering, comes to mind something that is marked by a state of negative experience, but, depending on the point of view, this sufering can become positive.
It is not a simple task to understand the existence of sufering. However, it is necessary that we will be able to un -derstand the dynamics of living with it, because, otherwise, it can become retribution or a punishment and, commonly is not a permanent manifestation, being able to cope with this feeling, so particular to each individual who is sufering.
Sufering is part of human nature, and there is something new, which may represent a merging of pleasure and pain. It has three sources: the body itself, the external world and the interpersonal relationship7.
Human evolution is part of life; however, there are many people who have resistance to evolution, since at some points in time of their existence have sufered frustrations while they were on the path of evolution. From then on, they go through life in fear, anxiety, worry, anger, among many other unpleasant feelings and emotions that block the natural low of life. The opportunities pass and are not perceived, or when they perceive the opportunities, the fear is too great, paralyzing actions and limiting choices.
The human suffering is something that acquires high complexity, because man can sufer in many ways and does not sufer from many others, depending on the vision of each one. Therefore, sufering obliges that sensitive life is subordinate to the life of the activities, which, repudiate fatalism, so that the sufering raises the feelings for the intentions of repair.
Anthropology and sufering
For Philosophical Anthropology, there are at least ive forms of sufering intimately rooted in multidimensional structure and pluri-relational of the human being: intrapersonal suffering (external and internal sufering); intrapersonal sufering; natural sufering; technical sufering and transcendent sufering8.
During the various stages of human life, from birth to death, one can observe the not sufering and sufering-pleasure, sepa -rated distinctively; but in common the sufering becomes modality imprecise and vague, that superimposes indistinguishable layers often inexpressible7.
In everyday life, the reality appears without disguises or masks. Many people may have diiculties to accept adverse situations, however the acceptance will allow the reduction of this sufering, even the thought that everything passes will allow hope in overcoming.
During the evolution of life, the human maturation comes with experience. The walk of life makes us become aware of who we are and what we want to be, and to progress, feeling the need to create and generate something. There is a greater tendency to develop the professional aspects, projects, marriage enhancement of intellectuality and procreation, as it perceives life as a big challenge in the quest for emotional and inancial
stability. In this phase, the body is already fully developed and ready for various activities.
The end of life corresponds to a period in which, typically, the sufering becomes transcendent, and this form of sufering is exclusive to the human species, being the origin of other ills, of inner order and interpersonal order8. In this period, the anxieties and the worldly desires are losing motivation. One feels an immense need for rest.
Experiencing the sufering makes human beings closer to each other, leading up to self-knowledge, so that one can live in greater fullness. It is task diicult to understand that the existential sufering is a component of our dynamic of living, and, on the contrary, seeing it only as a retribution or a punishment. On the other hand, it is only fair aspiring to joy and contentment; however, it is to them that if you want to stick, looking for disregarding its opposite - the alictions.
Thus, the fact that man, in his virtual nature, being prone to a future increasingly high, it is understandable the idea of successive acts of solidarity in indestructible enhancement through truth and good, and who may not retreat before the regret stimulating and savior of the mistakes of the past.
Sufering has a broad meaning and refers to a way of sufering that is not necessarily related with the physical or somatic of the human being, but with the scope of their interiority and all levels of experience which they imply8.
The human being suffers from suffering from various pers-pectives. On the one hand, there is the suffering abroad, which has the body as a physical dimension9. This type of suffering
becomes visible to our eyes, so the harmony of the human being with the whole of nature is total, because, in this, there is the feeling that something is wrong with the functioning of the body.
On the other hand, there is the sufering within the human, being the psychological, social and spiritual aspects. The anguish, despair, dread, fear, guilt, pain, pleasure and satisfaction are habitual ways of inner sufering. These forms of sufering has their center of gravity in the interiority of the human being, but is expres-sed in the face, the voice, the look and the set of corporeality8.
Currently, on can see the inability to understand the real meaning of sufering. Today we live in a "medicalized" world; the management of pain presupposes the medication of sufering with the indiscriminate use of anxiolytics, to help in the relief of nuisance taxes by sufering, at the same time, decreases the enjoyment of simple pleasures of everyday life.
Our technological and industrial reality can question: Is man responsible for his behavior under the impact of sufering? Is there is a God all-powerful, which harmonizes the existence of sufering?
If that God do not exist able to compensate for the sufering of the human being, nobody could respond by set of injustices and suferings found by life, and with this, only endure or desist10.
Nursing: a holistic view of sufering
The essence of nursing is caring, this manifests itself in the preservation of healthy potential of the human being and depends on an ethical conception that contemplates life as a valuable asset in itself, and to be a concept of broad spectrum, can incorporate multiple meanings and manifestations.
Care means sellessness, kindness, diligence, zeal, atten -tion, and materialized in the context of life in society. Caring in -volves interaction with the purpose of helping, usually in adverse situations, whether in personal dimension, or in social. It is a way of being with the other, with regard to the special issues of life and of their social relations, among these the birth, the promotion and restoration of health and death itself11.
Thus, the attempt to understand the value of Nursing care requires an ethical conception, respect to each other in their complexity, choice, individuality and at the same time pluralities, all characteristic of man.
The man, being vulnerable, needs a directed care their authenticity, uniqueness and truth. Nursing actions must understand the patient's weaknesses, because, from their identiication, is that care will be directed to the needs of each one. Caring in Nursing consists in eforts for the other, aiming to protect, promote and preserve, helping people to ind meanings in disease, sufering and pain, as well as in existence12. It has
as an essential premise to attempt to avoid that the other sufers, or that, to identify this sufering, carrying out measures to eradicate or minimize the sufering, being very important the attitude of understanding of who cares. This happens because hospitalization is distressing, by highlighting the fragility to which we are subject, as well as physical and emotional exposure.
The condition of sickness produces feelings such as disability, dependency, insecurity and feeling of loss of con-trol over oneself. The sick face hospitalization as a factor of depersonalization by the fact of recognizing the difficulty to maintain their identity, intimacy and privacy. The hospital environment is stressful by several factors, mainly the sick, losing control over the affects, and those which they depend on for their survival13.
The Nursing care has two distinct spheres: an objective, which refers to the development of techniques and procedures, and a subjective, which is based on sensitivity, creativity and
intuition to take care of another, the latter being quite relevant, because the object of care of Nursing is the human being14.
Sufering is inherent to life. Even in the absence of disease, it accompanies the human being throughout their journey, and is up to them such as experiences, how they appears and manifest. Every human being sufers, especially when they're ill, and at this stage,it is important to have at their side people available to take care, in order to understand this moment, because the sufering is part of human existence.
The cure of disease and the relief of pain and sufering from the birthplace of Hippocratic Medicine are accepted as the objectives of medicine. The disease destroys the integrity of the body, and the pain and sufering can be factors of disintegration of the human being. While today Medicine is even well equipped to combat pain, when it comes to dealing with sufering, it is still very rudimentary9. Sufering occurs when there is a possibility of an imminent destruction of person and continues until the threat of disintegration pass or until the integrity of the person is restored again in another way. It is pointed out that "direction and transcendence" ofer two lanes such as pain associated with the destruction of a part of the personality can be decreased. Giving meaning to condition sufered, often reduces or even eliminates the sufering associated with it. Transcendence is probably the most powerful way in which someone can have their integrity restored, after having sufered the disintegration of personality15.
Suffering is the experience of powerlessness with the prospect of unrelieved pain, disease situation that leads to interpret life devoid of meaning. Thus, sufering is more complex than the pain and, fundamentally, synonymous with quality of life diminished, occurring in situations such as those of serious diseases and prolonged that cause social disruption in the patient's life and consequently their families.
In the interim, it is understood the sufering from a broader concept, may be deined, in the case of illness, such as a feeling of anxiety, vulnerability, loss of control and threatens the integrity of I9.
In Homo patiens suffering is abandonment, it is more comprehensive and global than the pain, and is more profound. Sufering is a situation in which man inds himself before or after, a matter pending for all, a necessary step to maturity10.
Therefore, there is no way out for the state of sufering but recognizes it, looking at it from the front, with the courage to admit this fragility. Sufering leads to relection, self-awareness and ability to surprise us with overcoming, because it hurts, but makes us grow.
Sufering is not alien to human life, but it is completely present even under very diferent forms and modalities, it is an experience that accompanies human life throughout its course. Man sufers precisely because he is vulnerable and when he sufers or when he's ill, he perceives clearly his extreme vulnerability and heteronomy8.
The most common point of sufering is a disease, because it is there that the person experiences the physical pain and emotional at the same time. When man falls ill, he comes to realize his vulnerability. Thus, one should always take into consideration the factors that led the person to that state; how the person deals with the situation and the type of support they receive to reverse it. Sufering and sickness they relate to one another. Disease leads, in general, to some type of pain or sufering. On the other hand, there is sufering that does not directly relate to disease, such as the sufering of loneliness, of old age, of romance, of nostalgia; however, do not relate directly to the experience of becoming ill, yet that can converts into pathological type experiences8.
It is important to recognize that the sufering does not have a unitary manifestation for individuals, although it is the same for a family, culture or historical period. What is sufering for one is not necessarily for another. Hence,the importance of understanding that, in the quality of nurses, we must be prepared to take care in this perspective of complexity of the human being and of its ininite possibilities and potential, at the same time ofer a care that respects the uniqueness and, which also is integral and holistic.
This basic condition of the individual in the world cannot be deined only from the event, because the sufering depends on the signiication that assumes in time and space, as well as the body that it touches. Man sufers because he begins to realize his initude, which is sufering a dimension not only psychological, but mainly existential7.
Relecting on this condition is a fundamental point, because we live in a time dominated by technological "medicalization", in which escaping the pain is the rational and normal way. Thus, sufering is not allowed, as something that was in the human domain. Of course, this mindset takes its meaning from sufering intimate and personal and transforms it into a technical problem. We are in a secularized society in which the sufering has no sense and for this reason we are unable to perceive the meaning of sufering9.
Human Sufering and Nursing care
In the art of caring, consideration of sufering is essential because one can only take proper care of a human being, recognizing the double level of sufering, namely the exterior sufering and interior sufering. One can ight the pain from outside with therapy, pharmacology and the technological instruments, but the interior sufering calls for a distinct attention and human presence, the right word and the hard exercise of dialog8.
In this context, Nursing cannot overlook the sufering;we have to break the trend of caring in focus only on physical symptoms, as if they were a single root of troubles for the patient. Thus, in relation to care, must be valued important aspects, such as the dialog, listening, sensitivity, tenderness, empathy, because
the human being is a being in search of meaning. These are necessary conditions that the nurse should have to take care of someone who is sufering.
Helping to face sufering, without lies, is important, because the sufering also leads to self-knowledge, overcoming. It has the role to prepare, because the human being, despite the uncertainties, resists and is hopeful that this moment is a step to be addressed and that it will not help to escape it.
There is also an interface of the sufering to who is cared for with who cares. The nurse is no stranger to sufering and he needs to understand how a being is vulnerable to transcend and hence have better conditions for caring and monitoring. Therefore created to care and be care for and sometimes active, sometimes passive in this relationship.
In an approximation of the humanization of care of pain and human sufering, we have gone through a profound crisis of humanism, because we speak insistently of dehumanizing environments, technically perfect, but without a soul and human tenderness, both for those who are cared for as to who cares.
The human person more vulnerable by the disease has ceased to be the center of attention and began to be manipulated as a function of a particular order, and may be transformed into a learning object, the status of the researcher, or be guinea pigs for research, situations that compromises truth ethics that things have price and can be exchanged, changed and marketed, but people have dignity that must be respected9.
Hospital technology (equipment and medications) has the objective of increasingly trying to prolong life, but makes us relect also until that point does not prolong the sufering. One must have balance in the relationship of care that will not break the boundary between alleviating sufering and yet fostering it. One must not lose the focus of respect for human dignity and the ethics of care. The biomedical technological development establishes what is called triumph of "medicalization", leading to intervention procedures, the prolonged therapeutic obstinacy. This can result in the perpetuation of interventions and treatments that do not add substantial beneits for patients.
Besides an Anthropology of care, there is, either explicitly or implicitly, an ethic of care, whose purpose is to regulate the action of caring ethically, ie, under a rational perspective to analyze and analyze what it means to care for in a virtuous manner. The action of caring outlines serious and profound challenges of moral character and ethical, being absolutely essential relect around aspects such as: freedom, intimacy, justice and wellness8.
Contemporary Medicine has achieved a technical develo -pment so impressive that health professionals tend to consider an imperative its incorporation, running-if constantly the risk of claiming it as being an ethical requirement. Thus, what may have happened is a reversal of the relationship between Medicine and technology: no more is at the service of the irst, but, on the contrary, the Medical service of the technology.
to be global, extending to the care of the family, in an active search for measures to alleviate the distressing symptoms of the disease, in particular, the pain, and which can give meaning to the sufering of the patient, braving death as part of a natural process of human biography and not as an enemy to be "obstinately" faced.
It is important to realize that the care is not a one-way process, as there is a relationship between two human beings. O human being endowed of technical-scientiic, humanistic, and available for efective care and another being that is in need of help. Thus, one will feel satisied with the care and afection received and certainly will be thinking positively about the fact and emanating a corresponding feeling, which certainly beneicially relects in themselves.
FINAL CONSIDERATIONS
In a context of increasing "technologization" care, urgent recover an anthropological vision, holistic care to the human pain and sufering in its various dimensions, ie, physical, social, mental, emotional and spiritual, which combines technical-scientiic and human competence.
One of the goals in Nursing care is precisely alleviating the human sufering caused by disease; and with the amazing technological progress, arrived to illusion us to thinking that the technical management of the pain would be the solution. However, regardless of being a technical problem, the pain and sufering are in the ethical/human sphere and should be considered in its various interfaces.
REFERENCES
1. Martins JT, Robazzi MLCC. Nurses' work in intensive care units: feelings of sufering. Rev. latino-am. enfermagem. 2009 jan/fev;17(1):52-8. 2. Houaiss da língua portuguesa. 2ª ed. Rio de Janeiro (RJ): Objetiva; 2007. 3. Ricoeur P. O justo 2: Justiça e verdade e outros estudos. São Paulo (SP):
Martins Fontes; 2008.
4. Stepke FL. Bioética e medicina aspectos de uma relação. São Paulo (SP): Edições Loyola; 2006.
5. Almeida CH, Marques RC, Reis DC, Melo JMC, Diemert D, Gazzinelli
MF. A pesquisa cientíica na saúde: uma análise sobre a partici
-pação de populações vulneráveis. Texto & contexto enferm. 2010 jan/mar;19(1):104-11.
6. Lopes LR, Adorno RCF, Malitano APS, Takeiti BA, Silva CR, Borba PLO. Juventude pobre, violência e cidadania. Saúde soc. 2008 jul/set;17(3):63-76.
7. Brant LC, Gomes CM. A transformação do sofrimento em adoecimento: do nascimento da clínica à psicodinâmica do trabalho. Cienc. saude colet. 2004;9(1):213-23.
8. Torralba RF. Antropologia do cuidar. Petropoles (RJ): vozes; 2009. 9. Pessini L. Humanização e cuidados paliativos. 3ª ed. São Paulo (SP):
Edições Loyola; 2004.
10. Stork RY, Echevarria JA. Fundamentos de Antropologia:um ideal de excelência humana. São Paulo (SP): Instituto Brasileiro de Filosoia e Ciência "Raimundo Lúcio" (Ramon Llull); 2005.
11. Souza ML, Sartor VVB, Prado ML. Subsídios para uma ética da responsabilidade em enfermagem. Texto & contexto enferm. 2005 mar/abr;14(1):75-81.
12. Waldow VR, Lopes MJM, Meyer DE. Maneiras de cuidar, maneiras de ensinar. Porto Alegre (RS): Artes Médicas; 1998.
13. Pupulim JSL, Sawada NO. Nursing care and the invasion of patients' privacy: an ethical and moral issue. Rev. latino-am. enfermagem. 2002 maio/jun;10(3):433-8.
14. Ferreira MA. A comunicação no cuidado: uma questão fundamental na enfermagem. Rev. bras. enferm. 2006 maio/jun;59(3):327-30. 15. Cassel EJ. The nature of sufering and goals of medicine. New York
